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Pathophysiology of

Respiratory Failure and

Clinical Documentation Improvement

Nancy Reading RN, BS, CPC, CPC P, CPC I

AAPC Approved ICD 10CM Instructor

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Learning Goals

• Learn the anatomy, physiology and pathophysiology associated with

the respiratory system and respiratory failure

• Understand the difference between acute and chronic respiratory

failure

• Gain a working knowledge of documentation required from the

provider to support the diagnoses

• Become aware of the compliance risk involved

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The Respiratory System

• The respiratory system is made up of organs and tissues

that allow you to you breathe.

• Upper Airways,

• Lungs

• Blood vessels, and

• Muscles that enable breathing

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Respiratory System

https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022310/

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The Lungs

• Spongy air filled organs

• 2 Lungs on each side of the Thoracic Cavity

• Covered by Pleura (visceral pleura)

• There is also a layer of Pleura on the inner chest

wall (Parietal Pleura)

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The Pleural Cavity• The area between the 2 layers of Pleura is the pleural cavity

• A hollow space which allows the lungs to expand during

inspiration.

• The pleural membranes secrete a serous fluid that acts as a

lubricant between the 2 layers of Pleura.

• The 2 layers can move against one another without pain or

friction.

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The Lungs• There are 5 lobes of the lungs

• The Left Upper Lobe (LUL)

• The Left Lower Lobe (LLL)

• The Right Lower Lobe (RLL)

• The Right Middle Lobe (RML)

• The Right Upper Lobe (RUL)

• The inner surface of the lung would equal approx. ½ the size of a tennis court if stretched out.

http://www.innerbody.com/anatomy/respiratory/lungs

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The Lungs

• A bellows

• Air Exchange between our blood stream and the outside air.

• Oxygen in

• Carbon Dioxide Out

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Airways

• Carry air between the Lungs and the exterior of the body

• Carry oxygen-rich air to your lungs.

• Carry carbon dioxide rich air out of your lungs.

• Heat and humidifies the air

• Help with swallowing and speech

• Allow you to cough

• Secrete Mucous

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Airways

• Structures

• Nose and linked air passages (called nasal cavities)

• Mouth

• Larynx

• Trachea

• Tubes called bronchial tubes or bronchi, and their branches

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What is Mucus ?

• A Lubricant

• A Protective coating

• Works like fly paper to trap bacteria and other unwanted particulates

in the airways

• Comprised of water, epithelial cells, dead leukocytes, mucin and

inorganic salts.

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The Role of Mucus• The pseudostratified epithelium that lines the bronchi contains many

cilia and goblet cells.

• Cilia are small hair-like cellular projections that extend from the

surface of the cells.

• Goblet cells are specialized epithelial cells that secrete mucus to coat

the lining of the bronchi.

• Cilia move together to push mucus secreted by the goblet cells away

from the lungs.

http://www.smosh.com/smosh-pit/articles/6-cartoon-spokes-characters-would-be-

horrifying-real-life

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The Role of Mucous

• Particles of dust and even pathogens like viruses, bacteria

and fungi in the air entering the lungs stick to the mucus

and are carried out of the respiratory tract.

• In this way mucus helps to keep the lungs clean and free of

disease.

• Nicotine paralyzes the Cilia causing the lower airways to

become plugged and unable to exchange gases.

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Lungs and Vasculature

• Your lungs and linked blood vessels deliver oxygen to

your body and remove carbon dioxide from your body.

• In the lungs, the bronchi branch into thousands of

smaller, thinner tubes called bronchioles.

• The bronchioles end in bunches (think grapes) of tiny

round air sacs called alveoli.

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Lungs and Vasculature

• Each of these air sacs is covered in a mesh

of tiny blood vessels called capillaries.

• The capillaries connect to a network of

arteries and veins that move blood through

your body.

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The Alveoli• Alveoli are the functional units of the lungs that permit gas

exchange between the air in the lungs and the blood in the

capillaries of the lungs.

• Alveoli are found in small clusters called alveolar sacs at

the end of the terminal bronchiole.

• Each alveolus is a hollow, cup-shaped cavity surrounded by

many tiny capillaries.

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Alveolar Gas Exchange

https://www.dreamstime.com/stock-illustration-alveolus-gas-exchange-pulmonary-alveoli-capillaries-lungs-image48200122

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The Alveoli

• The walls of the alveolus are lined with simple squamous

epithelial cells known as alveolar cells.

• A thin layer of connective tissue underlies and supports the

alveolar cells.

• Capillaries surround the connective tissue on the outer border

of the alveolus.

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The Alveoli

• Where the walls of a capillary touch the walls of an alveolus

is referred to as the respiratory membrane.

• Gas exchange occurs freely between the air and blood at

the respiratory membrane,

• The respiratory membrane and capillary membranes are a

single cell layer thick.

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Alveolar Septal Cells

• Produce alveolar fluid

• Coat the inside of the alveoli

• Acts as a surfactant that keeps the alveoli moist

• Helps to maintain the elasticity of the lungs and keeps

thin walls from collapsing

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Alveolar Macrophages

• Help keep the lung free from infections

• Capture and eat outside pathogens and other items

foreign to the body

• Alveolar macrophages eat the bacteria by

phagocytosis

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Phagocytosis

• The white blood cell attaches its membrane to the

membrane of the bacterium using molecules

called surface receptors embedded in the white

blood cell's membrane.

• Once attached to each other, the membrane of

the white blood cell swells outward around the

bacterium and engulfs it.

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Phagocytosis• The membrane enclosing the bacterium pinches off

and the result is a little pouch, called a phagosome,

that contains the offending bacterium inside of the

white blood cell.

• With the bacterium safely imprisoned inside the

white blood cell brings digestive enzymes into the

phagosome.

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Alveolar Macrophages

• The enzymes digest the bacterium resulting in

harmless particles.

• The Macrophage can either use the by

products of the digested bacteria or release

them out of the cell.

http://study.com/academy/lesson/phagocytosis-definition-process-

types.html

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Phagocytosis

http://study.com/academy/lesson/phagocytosis-definition-process-types.html

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Muscles of Respiration• Diaphragm

• Intercostal muscles

• Abdominal muscles

• Muscles in the neck and collarbone area

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Blood Flow Through the Lungs• The pulmonary artery and its branches deliver

venous blood rich in carbon dioxide to the

capillaries that surround the air sacs.

• Inside the air sacs, carbon dioxide moves from the

blood into the air.

• Once the hemoglobin is free of CO2 the oxygen

moves from the air into the blood in the capillaries.

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Blood Flow Through the Heart

• The oxygen-rich blood travels to the heart through

the pulmonary vein and its branches.

• The heart pumps the oxygen-rich blood out to the

body via the arterial system.

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The Act of Ventilation• Negative Pressure Ventilation

• Need a pressure differential between outside air and inside the alveoli

• Respiratory muscles expand and create a negative pressure inside the

alveoli

• Causes air to come into the lungs in the act of Inhalation

• When Respiratory muscles contract and decrease the size of the

thoracic cavity the pressure in the alveoli increases and the air is

expelled or exhaled.

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Lung Volumes• Total air volume of the lungs is about 4 to 6 liters and

varies with a person’s size, age, gender, and respiratory health.

• Lung volumes are measured clinically by a device known as a spirometer

• Normal shallow breathing only moves a small fraction of the lungs’ total volume into and out of the body with each breath. This volume of air, known as tidal volume, usually measures only around 0.5 liters

http://www.innerbody.com/anatomy/respiratory/lungs

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Breathing• Conscious Control

• Cerebral Cortex of the brain

• Unconscious control

• Controlled by the respiratory center in the brainstem

• Monitors the concentration of gasses in the blood

stream and adjusts the respiratory rate accordingly

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Lung Volumes• The volume of air exchanged during deep

breathing is known as vital capacity

• Ranges between 3 to 5 liters, depending on the

lung capacity of the individual.

• A residual volume of around 1 liter of air remains

in the lungs at all times, even during a deep

exhalation.

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Respiratory Failure Lay Definition• Respiratory failure is a condition in which not enough

oxygen (O2) passes from your lungs into your blood.

• Your body's organs, such as your heart and brain, need oxygen-rich blood to work well.

AND/OR

• Carbon Dioxide (CO2) is not adequately removed from the lungs

• This can cause problems with body pH such as respiratory acidosis

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Etiologies

• A wide range of of etiologies can be

responsible for RF

• Primary pulmonary pathologies or

• Initiated by extra-pulmonary pathology

• Causes are often multifactorial

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Etiologies

• Can be caused by abnormalities in:

• Central Nervous System impairment due to e.g. drugs, metabolic encephalopathy, CNS infections, increased ICP, OSA, Central alveolar hypoventilation

• Spinal cord trauma or disease e.g. transverse myelitis

• Neuromuscular diseases e.g. polio, tetanus, M.S., M.Gravis, Guillain-Barre, critical care or steroid myopathy)

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Etiologies• Can be caused by abnormalities in:

• Chest wall dysfunction or deformity e.g. Kyphoscoliosis, obesity)

• Upper airway trauma or disease e.g. obstruction from tissue enlargement, infection, mass; vocal cord paralysis, tracheomalacia

• Lower airway disease e.g. bronchospasm, CHF, infection

• Lung parenchyma disease or disruption due to e.g. infection, interstitial lung disease

• Impact from Cardiovascular system

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Acute Versus Chronic

• Important Distinction in ICD 10CM Coding

• Provider MUST make the statement

• Acute Respiratory Failure

• Chronic Respiratory Failure

• Important in that the diagnoses here drive different DRGs.

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Respiratory Failure• Respiratory Failure is not a disease

• It is the consequence of problems interfering with the ability to breathe.

• The body is no longer to perform the functions of respiration

• Delivering oxygen to the blood and

• Removing Carbon Dioxide from the blood

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Types of Respiratory FailureType Typical Causes

Acute Ventilatory Drug Overdose

Oxygenation Pneumonia

Chronic Ventilatory Neuromuscular Disease

Oxygenation Pulmonary fibrosis

https://www.thoracic.org/patients/patient-resources/breathing-in-

america/resources/chapter-20-respiratory-failure.pdf

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Chronic Respiratory Failure

• Results from progressive disease process over

time

• Main cause of death in COPD and Lou

Gehrig’s Disease

• Third leading cause of death in the US

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Acute

• The sudden onset of a process resulting in loss of the

ability to ventilate adequately or to provide sufficient

oxygen to the blood and systemic organs.

• The pulmonary system is no longer able to meet the

metabolic demands of the body with respect to

oxygenation of the blood and/or CO2 elimination.

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Arterial Blood Gas • Measures the following

• pH

• Level of Oxygen

• Level of Carbon Dioxide

• Drawn from an Artery

• Lets the provider know how well the patient can move oxygen from the air

into the blood stream and how well they remove Carbon Dioxide.

http://www.webmd.com/lung/arterial-blood-gases

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pH• Measures the acidic or basic (alkaline) nature of a solution.

• The pH scale ranges from 0 (most acidic) to 14 (most basic).

• A neutral solution such as water has a pH of 7.

• Acidic Solutions have a pH less than 7, with 0 being the most acidic.

• Alkaline solutions have a pH greater than 7, with 14 being the most basic.

http://www.webmd.com/hw-popup/ph

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PaO2

• Refers to the partial pressure of oxygen in the blood

• Refers to the pressure of oxygen dissolved in the blood

• Tells how well oxygen is able to move from the alveoli in

the lungs into the blood.

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PaCO2

• Refers to the partial pressure of Carbon

Dioxide dissolved in the blood

• Tells how well the Carbon Dioxide is removed

from the blood stream

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Physiologic pH

• Measures the number of Hydrogen ions (H+) in the

blood stream

• Physiologic pH is between 7.35 and 7.45

• A pH of less than 7.35 is referred to as acidosis

• A pH of greater than 7.45 is referred to as Alkalosis

• The body is slightly alkaline

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HCO3

• HCO3 is the chemical representation of

Bicarbonate

• Bicarbonate in the blood stream acts as a buffer

to keep the blood pH from becoming too acidic

or basic (alkaline).

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Oxygen Content Versus Oxygen Saturation

• Oxygen Content - O2CT – Measures how

much oxygen is in the blood

• Oxygen Saturation – Sa02 - Measures how

much of the Hemoglobin in the red blood

cells is carrying oxygen.

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Hemoglobin (Hb)

• Most of the O2 that diffuses into the pulmonary capillary blood

rapidly moves into the red blood cell (RBC) and chemically

attaches to hemoglobin

• Each RBC contains 280 million Hb molecules

• Each hemoglobin molecule has the ability to combine with

four oxygen molecules.

• The amount of O2 bound to hemoglobin is directly related to

the partial pressure of oxygen (PO2).

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Terms for Hemoglobin• Oxyhemoglobin (HbO2)

• Hemoglobin bound with oxygen

• Oxygen Saturation (SO2)

• Four O2 molecules bound to a Hb molecule = 100% saturated

• Three O2 molecules bound to a Hb molecule =75% saturated

• Two O2 molecules bound to a Hb molecule = 50% saturated

• One O2 molecule bound to a Hb molecule = 25% saturated

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ABG Normal Values at Sea Level

• Partial pressure of oxygen (PaO2): 75 - 100 mmHg

• Partial pressure of carbon dioxide (PaCO2): 38 - 42 mmHg

• Arterial bloot pH: 7.38 - 7.42

• Oxygen saturation (SaO2): 94 -100%

• Bicarbonate - (HCO3): 22 - 28 mEq/L

https://medlineplus.gov/ency/article/003855.htm

Note:

mEq/L = milliequivalents per liter;

mmHg = millimeters of mercury

At altitudes of 3,000 feet and

above, the oxygen value is lower.

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Acute Hypercapnic Respiratory Failure

• Acute Hypercapnic Respiratory Failure

• A rise in arterial carbon dioxide levels is called hypercapnia ( with normal or near normal Oxygen levels).

• Excess CO2 causes the pH to drop, a symptom of this is a pH < 7.30

http://emedicine.medscape.com/article/167981-overview

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Chronic Hypercapnic Respiratory Failure

• Chronic Hypercapnic Respiratory Failure

• pH not decreased far from baseline

• Usually higher HCO3, due to compensation

from kidneys

http://emedicine.medscape.com/article/167981-overview

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Chronic Hypoxemic Respiratory Failure

• Chronic Hypoxemic Respiratory Failure

• Patient will have low oxygen levels and normal or

near normal Co2 levels

• May see polycythemia or

• Right Sided Heart Failure (Cor Pulmonale)

http://emedicine.medscape.com/article/167981-overview

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Classifications• Type 1 (Hypoxemic ) - PaO2 < 60 mmHg on room

air or O2 saturation < 90%

• Usually seen in patients with acute pulmonary

edema or acute lung injury.

• These disorders interfere with the lung's ability to

oxygenate blood as it flows through the pulmonary

vasculature.

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Classifications

• Type 2 (Hypercapnic/ Ventilatory ) - PCO2 > 50 mmHg (if not a chronic CO2 retainer).

• This is usually seen in patients with an increased work of breathing due to airflow obstruction or

• Decreased respiratory system compliance, with decreased respiratory muscle power due to neuromuscular disease, or

• With Central respiratory failure and decreased respiratory drive

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Classifications

• Type 3 (Peri-operative). This is generally a subset

of type 1 failure but is sometimes considered

separately because it is so common.

• Type 4 (Shock) - secondary to cardiovascular

instability.

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Hypoxemic Respiratory Failure• Physiologic Causes of Hypoxemia

• Low FiO2 (high altitude)

• Hypoventilation

• V/Q mismatch (low V/Q)

• Shunt (Qs/Qt)

• Diffusion abnormality

• Venous admixture (low mixed venous oxygen)

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Ventilatory / Hypercapnic Respiratory Failure

• Physiologic causes of Hypercapnia:

• Increased CO2 production (fever, sepsis, burns, overfeeding)

• Decreased alveolar ventilation

• Decreased RR

• Decreased tidal volume (Vt)

• Increased dead space (Vd)

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Hypercapnia Independent of Hypoxemia• Hypercapnia results from either increased CO2 production

secondary to increased metabolism resulting from issues such as:

• sepsis,

• fever,

• burns,

• Overfeeding

OR…….

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Hypercapnia Independent of Hypoxemia• Decreased CO2 excretion.

• CO2excretion is inversely proportional to alveolar ventilation (VA).

• VA is decreased if total minute ventilation is decreased - secondary to either a decreased respiratory rate (f) or

• A decrease in tidal volume (Vt);

• Or if the deadspace fraction of the tidal volume is increased (Vd/ Vt).

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Causes of Decreased Alveolar Ventilation

• Decreased CNS drive ( CNS lesion, overdose, anesthesia).

• The patient is unable to sense the increased PaCO2. The patient "won't breathe”.

• The Medulla senses Carbon Dioxide levels

• When PaCO2 is elevated it causes Co2 to pass through the blood brain barrier and this causes H+ ions to form creating an acidosis.

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Causes of Decreased Alveolar Ventilation

• Neuromuscular disease

• Myasthenia Gravis,

• ALS,

• Guillian-Barre ,

• Botulism,

• Spinal cord disease,

• Myopathies

The patient is unable to

neurologically signal the

muscles of respiration or has

significant intrinsic

respiratory muscle

weakness. The patient "can't

breathe

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Causes of Decreased Alveolar Ventilation

• Asthma/ COPD

• Pulmonary fibrosis

• Kyphoscoliosis

Increased Work Of Breathing leading to respiratory muscle

fatigue and inadequate ventilation.

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Causes of Decreased Alveolar Ventilation

• Causes of increased dead space ventilation

• Pulmonary embolus,

• Hypovolemia,

• Poor cardiac output, and

• Alveolar over distension.

Increased Physiologic Dead Space (Vd) - When blood flow to some alveoli is significantly

diminished, CO2 is not transferred from the

pulmonary circulation to the alveoli and CO2 rich blood is

returned to the left atrium.

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• Accurate documentation drives accurate reporting of

ICD-10-CM diagnosis codes

For accurate reporting of ICD-10-CM diagnosis codes,

the documentation should describe the patient’s

condition, using terminology which includes specific

diagnoses as well as symptoms, problems, or reasons

for the encounter. There are ICD-10-CM codes to

describe all of these.

Documentation Requirements in the Outpatient Setting

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• If patient care is not documented by the

physician or provider, it did not happen for the

purposes of medico-legal challenges and

coding and reimbursement.

The Golden Rule of Clinical Documentation

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Clinical Documentation

IN

Lost

OUT =

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• Provider must tie cause and effects together

• Infection due to a procedure

• Sepsis due to a specific organism

• Heart Disease due to Hypertension

• Renal Failure due to Heart Disease

• Neuropathy due to Diabetes

• Complication related to a procedure

Documentation of Causal Relationships

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• Coding rules

• Require provider to document the findings in the progress notes from diagnostic tests, e.g.

• Pathology reports

• Cultures

• Radiology Reports

• Cardiology Reports

• ABGs

Study Results

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DRG • Section 1886(d) of the Social Security Act (the Act) sets forth a

system of payment for the operating costs of acute care hospital inpatient stays under Medicare Part A (Hospital Insurance) based on prospectively set rates.

• This payment system is referred to as the inpatient prospective payment system (IPPS). Under the IPPS, each case is categorized into a diagnosis-related group (DRG).

• Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG.

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DRG

• The base payment rate is divided into a labor-related and

nonlabor share.

• The labor-related share is adjusted by the wage index

applicable to the area where the hospital is located, and if the

hospital is located in Alaska or Hawaii, the nonlabor share is

adjusted by a cost of living adjustment factor.

• This base payment rate is multiplied by the DRG relative

weight.

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DRG • Diagnosis Related Grouper - Inpatient Prospective Payment

System (IPPS)

• Driven by Principal diagnosis -

• When a patient is admitted to the hospital, the condition

established after study found to be chiefly responsible for

occasioning the admission to the hospital should be sequenced

as the principal diagnosis.

• Not always the same as the admitting diagnosis; e.g. Headache

turns out to be brain tumor.

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My Favorite Reference for MS DRGs

• http://library.ahima.org/doc?oid=1

06590#.WH2HMxQomLU

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Medical Severity DRG’s• A new DRG system, called Medicare Severity DRGs

(MS-DRGs), was adopted for use with Medicare’s

Inpatient Prospective Payment System. It became

effective with discharges occurring on or after October

1, 2007.

• The MS-DRG structure was also adopted for use with

the Long-Term Care Hospital Prospective Payment

System (referred to as MS-LTC-DRGs).

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MS DRG

• MS-DRGs introduced a three-tiered

structure:

• Major complication/comorbidity (MCC),

• Complication/comorbidity (CC),

• No complication/comorbidity (non-CC).

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MS DRG

• MCCs reflect secondary

diagnoses of the highest level of

severity.

• CCs reflect secondary diagnoses

of the next lower level of severity.

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MS DRG• Secondary diagnoses which are not MCCs

or CCs (the non-CCs) are diagnoses that

do not significantly affect severity of illness

or resource use.

• The MS-DRGs provides better recognition

of severity of illness than the traditional

CMS DRG system.

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APR DRGs

• Comprised of

• A clinical model and

• Four severity of illness subclasses

• Four risk of mortality subclasses for each

base APR DRG.

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APR DRGs

• These subclasses are broken down into four levels minor,

• Moderate,

• Major, and

• Extreme.

• Used by hospitals for internal quality improvement and by many states for public reporting.

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DRG

• 189 - Pulmonary Edema and Respiratory Failure

• https://www.cms.gov/ICD10manual/Fullcode_cms

/P0109.html

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Principal Diagnoses that Drive DRG 189

• J182 Hypostatic pneumonia, unspecified organism

• J681 Pulmonary edema due to chemicals, gases, fumes and vapors

• J810 Acute pulmonary edema

• J811 Chronic pulmonary edema

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Principal Diagnoses that Drive DRG 189

• J951Acute pulmonary insufficiency following thoracic surgery

• J952Acute pulmonary insufficiency following nonthoracic surgery

• J953Chronic pulmonary insufficiency following surgery

• J9582 Postprocedural respiratory failure

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Principal Diagnoses that Drive DRG 189

• J9600 Acute respiratory failure, unspecified whether

with hypoxia or hypercapnia

• J9601 Acute respiratory failure with hypoxia

• J9602 Acute respiratory failure with hypercapnia

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Principal Diagnoses that Drive DRG 189

• J9610 Chronic respiratory failure, unspecified whether

with hypoxia or hypercapnia

• J9611 Chronic respiratory failure with hypoxia

• J9612 Chronic respiratory failure with hypercapnia

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Principal Diagnoses that Drive DRG 189

• J9620 Acute and chronic respiratory failure,

unspecified whether with hypoxia or hypercapnia

• J9621 Acute and chronic respiratory failure with

hypoxia

• J9622 Acute and chronic respiratory failure with

hypercapnia

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Principal Diagnoses that Drive DRG 189

• J9690 Respiratory failure, unspecified, unspecified

whether with hypoxia or hypercapnia

• J9691 Respiratory failure, unspecified with hypoxia

• J9692 Respiratory failure, unspecified with

hypercapnia

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Clinical Validation• Clinical Documentation Improvement Specialist

(CDIS or CDIP credentials are available)

• The medical record must clinically support the diagnoses listed on a claim.

• The practice of medicine is not exact but for many of the conditions in question there are key associated symptoms and treatments that must be in the record.

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Clinical Findings• Respiration >30 breaths/minute,

• Central cyanosis

• Use of accessory muscles of respiration

• Po2 <60 mm Hg

• Pco2 >50 mm Hg

• pH <7.35

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Intensity of Management

• Medications –

• Bronchodilators

• Steroids

• Antibiotics

Additional Oxygen –

• Venti Mask

• Re-breathing mask

• biPAP, cPAP

(unless on this at

home)

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Intubation and Ventilation

• Not required for diagnosis of respiratory failure

• BUT –

• Does not count if to protect airway only

• Does not count if routine post operative treatment includes vent support such as open heart surgery

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Questions Regarding Documentation

• Query the provider

• Provide your findings

• Ask open ended questions

• e.g. Are these findings associated with any pertinent diagnoses

• Never ask a yes or no question

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Case Study• A patient presents to the emergency department

with an acute exacerbation of COPD.

• Clinical Findings - RR 31, SaO2 – 88% RA, mild

use of accessory muscles of respiration, pH – 7.30

• The patient is admitted to the ICU and treated with

steroids and O2 but does not require intubation or

mechanical ventilation.

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Case Study

• The hospitalist documents the diagnoses as acute

exacerbation of COPD with severe hypoxemia.

• This documentation is coded to MS-DRG 192: COPD

without Complication or Comorbidity.

• The payment is $3,946, at a hospital-specific rate of

$5,500. Geometric mean length of stay is 3.3 days.

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Case Study

• If the circumstances and ABG measurements

support it, however, the hospitalist must

document acute respiratory failure, which

yields a longer expected length of stay and a

higher payment.

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Case Study• The diagnoses can then be documented as

• Acute respiratory failure due to COPD

• Acute exacerbation of COPD.

• This documentation is coded to MS-DRG 189: Respiratory Failure.

• The payment is $7,400, and the geometric mean length of stay is 4.7 days

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Related MS DRGs• Of the total number of 2009 Medicare claims assigned to

the MS-DRGs for COPD and acute respiratory failure,

• 27% were in DRG 189—that is, acute respiratory failure

as the principal diagnosis.

• The remaining 73% of claims listed COPD as the

principal diagnosis, and were divided into three

categories based on the presence or absence of

complications or comorbidities, as follows

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Related MS DRGs• MS-DRG 192: COPD without Complication or

Comorbidity.

• Payment of $3,946, at a hospital-specific rate of $5,500. Geometric mean length of stay is 4.7 days.

• MS-DRG 191: COPD with Complication or Comorbidity

• Payment of $5,292, at a hospital-specific rate of $5,500. Geometric mean length of stay is 4.0 days.

http://www.acphospitalist.org/archives/2010/04/coding.htm

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Related MS DRGs• MS-DRG 190: COPD with Major Complication or

Comorbidity.

• Payment of $6,642, at a hospital-specific rate of $5,500. Geometric mean length of stay is 3.2 days.

http://www.acphospitalist.org/archives/2010/04/coding.htm

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Hospital Acquired Conditions (HAC)

• On February 8, 2006 the President signed the Deficit

Reduction Act (DRA) of 2005. Section 5001(c) of DRA

requires the Secretary to identify, by October 1, 2007, at

least two conditions that are (a) high cost or high volume or

both, (b) result in the assignment of a case to a DRG that

has a higher payment when present as a secondary

diagnosis, and (c) could reasonably have been prevented

through the application of evidence based guidelines.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/HospitalAcqCond/icd10_hacs.html

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Hospital Acquired Conditions (HAC)

• For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present. Section 5001(c) provides that CMS can revise the list of conditions from time to time, as long as it contains at least two conditions.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/HospitalAcqCond/icd10_hacs.html

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POA Indicator• Present On Admission

• Y Diagnosis was present at the time of inpatient admission

• N Diagnosis was not present at the time of inpatient admission

• U Documentation insufficient to determine if the condition was present at the time of admission.

• W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of admission.

• 1 Unreported/Not Used Exempt from POA reporting

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Peri-Operative Respiratory Failure

• May or may not be seen as a HAC

• The Provider must document a cause and effect

relationship between the surgery or a

complication of surgery and the respiratory failure

• Make certain to code all applicable diagnoses

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Recovery Audit Contractor Findings • Post Payment Audit for Medicare Contractors.

• Audit for over payments

• Will change the principal diagnosis if not documented

• Will recode if clinical evidence is not supportive of

documented diagnoses

• This can result in a lower paying DRG

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Audit Example

• History of present illness states that patient was

discharged home on Friday afternoon and then re-

admitted this morning. He has a history of interstitial

infiltrates and sarcoidosis, chronic anemia and renal

insufficiency.

• Discharge summary lists the final diagnosis as

hypoxemia, dyspnea, anxiety, anemia, and shingles

http://www.hcpro.com/HOM-272794-5728/Examine-RAC-audit-of-acute-

respiratory-failure.html

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Audit Result

• Auditor Finding: There is no physician documentation of acute

respiratory failure.

• Action: The auditor deleted respiratory failure code 518.81 and

changed the principal diagnosis to hypoxemia code 799.02. This

resulted in a MS–DRG change from 189 to 206–Other Respiratory

System Diagnoses without Major Complication and Comorbidity

(MCC). These changes resulted in a finding for overpayment.

http://www.hcpro.com/HOM-272794-5728/Examine-RAC-audit-of-acute-

respiratory-failure.html

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RAC Audit Findings

• An 71-year-old male was admitted with complaints of dry cough X

3 weeks. The patient was admitted through the emergency

department (ER) and was assessed for wheezing, rhonchi and

coughing. History and physical (H&P) assessment noted acute

respiratory failure secondary to exacerbation of chronic

obstructive pulmonary disease (COPD). Daily progress notes cite

the diagnosis of acute respiratory failure secondary to

exacerbation of COPD

http://www.hcpro.com/HOM-272794-5728/Examine-RAC-audit-of-acute-

respiratory-failure.html

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Rac Audit Findings

• Final diagnosis on the discharge summary is acute

respiratory failure secondary to COPD exacerbation.

Additional documentation sheet supplied in the record

list the patient's diagnoses as: Principal diagnosis:

COPD exacerbation; Other diagnoses: hypertension,

congestive heart failure (CHF), Insulin dependent

diabetes mellitus (IDDM),and Osteoarthritis.

http://www.hcpro.com/HOM-272794-5728/Examine-RAC-audit-of-acute-

respiratory-failure.html

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Auditor Recoded• Even though the physician documented acute respiratory failure in the

H&P, daily progress notes, and discharge summary, the RAC auditor removed the code for acute respiratory failure (ICD 10 code J96.00), substituting code (hypoxemia), and changed the principal diagnosis to COPD exacerbation because the RAC reviewer determined that the clinical evidence in the medical record did not support respiratory failure as a valid diagnosis as to be coded and thus could not be sequenced as the principal diagnosis.

• Therefore, the MS-DRG changed from 189 (pulmonary edema and respiratory failure) with a current relative weight of 1.2809 to 192 (chronic obstructive pulmonary disease without CC/MCC) with a current relative weight of 0.7220.

http://www.hcpro.com/hom-272794-5728/examine-rac-audit-of-acute-respiratory-

failure.html

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MLN Matters® Number: MM6954 Revised

• This clinical review judgment involves two steps:

• The synthesis of all submitted medical record information

(e.g. progress notes, diagnostic findings, medications,

nursing notes, etc.) to create a longitudinal clinical picture

of the patient; and

• The application of this clinical picture to the review criteria

to determine whether the clinical requirements in the

relevant policy have been met.

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Keep Expectations Reasonable• Look at what is said and left unsaid

• We are not the providers

• Never force the issue

• Let the provider arrive at his or her own

conclusion

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Questions